Ann Thorac Surg 2005;79:1411-1412
© 2005 The Society of Thoracic Surgeons
Case report
Posterior Intrathoracic Neurinoma Cure: A Transforaminal Resection After a Thoracotomy
Jean Ader Jules, MA, MD*,a,
Jose M. Guarnieri, MDb,
Barbara Alkofer, MDa,
Jean Philippe Le Rochais, MDa,
Philippe Icard, MDa
a Department of Thoracic and Cardiovascular Surgery, Cean, France
b Department of Neurologic Surgery, Centre Hospitalier Universitaire de Caen, Caen, France
Accepted for publication October 10, 2003.
* Address reprint requests to Dr Jules, Service de Chirurgie Thoracique et Cardiovasculaire, Centre Hospitalier Universitaire de Caen, Avenue Côte de Nacre, 14033 Caen Cedex, France
jules-ja{at}chu-caen.fr
icard-p{at}chu-caen.fr
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Abstract
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Posterior intrathoracic neurogenic tumors often have an intraforaminal extension. Ten percent have an extension intraspinal and are called "dumbbell tumors." The surgically recommended techniques used to treat these conditions may have been applied too systematically, mainly when the diameter of the foramen was obviously enlarged and the possibility of removing the tumor existed. We report two cases to stress the importance of assessing the size of the intervertebral foramina in planning neurinoma cure.
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Introduction
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Choosing the surgical strategy best adapted to treat the posterior intrathoracic neurogenic tumors that have intraforamina or intraspinal extensions is an immediate challenge and also a controversial subject. Various approaches were proposed, each one as being better than the other [1–4]. After a series of 14 patients for the last 5 years (of which two were dumbbell tumors), we realized that assessing the size of the foramina may be an excellent clue for determining surgical strategy.
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Case Reports
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Patient 1
A 71-year-old woman was referred to our thoracic and cardiovascular surgery unit for the management of a posterior intrathoracic mass, disclosed during her workup for a worrying dyspnea. Assessments (chest computed tomography and magnetic resonance imaging) showed a tumor (approximately 4.5 cm diameter) located in the left paravertebral sulcus at T-3, which slipped into the adjacent intervertebral foramen and became momentously widened. Shown on magnetic resonance imaging, the tumor had reached the spinal canal, but there was no cord compression discovered nor did the dura mater trespass (Fig 1).
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Fig 1. Axial chest computed tomographic scan showing tumor intraspinal invagination and widening of adjacent intervertebral foramen.
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Surgery was planned after ruling out Recklinghausen's disease and documenting the emergence of her Adamkiewicz's artery by means of thoracic aortography.
On the day of her operation, the patient was placed in a semiprocumbent right lateral position on a tilt table with roll capabilities along the transverse plane. Her back and left hemithorax were widely cleansed and draped, allowing access to the vertebral spine for a possible hemilaminectomy, if this procedure became essential for this patient.
With a neurosurgeon as part of our operating team, we performed a posterolateral thoracotomy through a standard skin incision sloped upward near the spinous processes at its medial tip. The tumor was removed entirely from the intervertebral foramen, and pathology was consistent with neurinoma. Recovery was both complete and uneventful.
Patient 2
With a 6-month prior admission, a 45-year-old woman with an unremarkable past history had visited her family doctor because of a 2-year history of intermittent nonradiating right shoulder and lower back pain. Specific investigations (magnetic resonance imaging and computed tomographic scanning of the thoracic spine) revealed a left-sided tumor (4.5 cm diameter) at T-3 that had intruded into the intervertebral foramen and had turned toward the spinal canal (Fig 2).
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Fig 2. Magnetic resonance imaging coronal view of the thoracic spine showing intervertebral foramen widening.
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The patient was first screened for Recklinghausen's disease. At the same time that the site of origin of her Adamkiewicz's artery was checked, she was scheduled for surgery.
The management of Patient 2 was similar to that of Patient 1. Patient 2 underwent a left posterolateral thoracotomy. Her tumor, which was a neurinoma, was totally removed through the intervertebral foramen. Her postoperative course was unremarkable, and she is now enjoying a normal life.
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Comment
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Thoracic neurinomas are usually studied under the title of neurogenic tumors of the posterior mediastinum. Recommended treatment for these tumors has long been through a posterior approach by laminectomy, hemilaminectomy alone [5] or with partial costotransversectomy [3], or through a combined posterior and lateral approach performed either in one stage [1, 2] or in two stages with the ability to follow-up one another at once or at a later date [2]. This combined posterolateral approach is often very hard and long, even when a video- assisted thoracoscopic resection is initially performed [4]. Sometimes these practices have considerable aftereffects, such as recurring dorsalgia and problems of instability of the vertebral column in younger people [1, 5]. Thus it is essential to individualize each patient in order to plan the suitable preoperative surgical strategy [1, 3]. Nowadays this seems to be more obvious, considering the progress of modern imaging (the computed tomographic scan and magnetic resonance imaging), which make it possible to clearly visualize the foramina and tumor intraspinal extensions [1, 2, 6]. Therefore we particularly draw attention to the importance of taking the foramen widening into account to define this surgical approach.
During the 5 years that we operated on the series of 14 patients for posterior intrathoracic neurogenic tumors (of which two were dumbbell tumors), we completely removed both dumbbell tumors through the transforaminal route.
Incidentally, Grillo did evoke this possibility by saying, "If the spinal extension can be removed by foraminotomy via the transthoracic incision, the laminectomy can be avoided" [4].
Therefore it seems logical to propose to the patient a short posterolateral thoracotomy and a transforaminal tumor resection to treat his pathology after sufficient widening of the foramen is established. Intraspinal tumor prolongation, with a maximum of 2 to 3 cm [6], is to be without bulge. In other words, the volume of the intraspinal extension of the tumor must be lower than the diameter of the opening of the enlarged foramen. This small interesting remark seems to be the happy medium to avoid the overly used systematic application of the combined procedure and improper use of our techniques.
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References
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- Grillo HC, Ojemann RG, Scannell JG, et al. Combined approach to "dumbbell" intrathoracic and intraspinal neurogenic tumors. Ann Thorac Surg. 1983;36:402–407[Abstract]
- Akwari OE, Payne WS, Onofrio BM, et al. Dumbbell neurogenic tumors of the mediastinum: diagnosis and management. Mayo Clin Proc. 1978;53:353–358[Medline]
- Takamura Y, Uede T, Igarashi K, et al. Thoracic dumbbell-shaped neurinoma treated by unilateral hemilaminectomy with partial costotransversectomy. Neurol Med Chir (Tokyo). 1997;37:354–357[Medline]
- Vallières E, Findlay JM, Fraser RE. Combined microneurosurgical and thoracoscopic removal of neurogenic dumbbell tumors. Ann Thoracic Surg. 1995;59:469–472[Abstract/Free Full Text]
- Sridhar K, Ramamurthi R, Vasudevan MC, et al. Limited unilateral approach for extramedullary spinal tumours. Br J Neurosurg. 1998;12(5):430–433[Medline]
- Ricci C, Rendina EA, Venuta F, et al. Diagnostic imaging and surgical treatment of dumbbell tumors of the mediastinum. Ann Thorac Surg. 1990;50:586–589[Abstract]
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Abstract
Introduction
